Denials
October – December 2022, Outpatient Services Medical Review Top Denial Reason Codes
We encourage all providers to review this information when filing claims to prevent denials and to ensure their claims are processed timely. The following information affects providers billing the 13X bill type in South Carolina, North Carolina, Virginia and West Virginia.
|
Rank |
Denial Code |
Denial Description |
# Claims |
|---|---|---|---|
|
1 |
No Medical Necessity |
4157 |
|
|
2 |
No Diagnosis/Documentation to Support Medical Necessity (Bene Liable/ Provider Liable) |
4135 |
|
|
3 |
NCD Denial — HCPCS/Diagnosis Matched National Coverage Determination (NCD) Table List ICD9-CM Deny Codes |
228 |
|
|
4 |
Documentation Submitted Does Not Support Medical Necessity |
224 |
|
|
5 |
Auto Denial — Requested Records Not Submitted |
209 |
|
|
6 |
Service Is Subject to Prior Authorization and No UTN Is Present on the Claim |
169 |
|
|
7 |
No Certification |
60 |
|
|
8 |
Item of Service Is Subject to Prior Authorization and No Prior Authorization Was Requested for the Item of Service |
53 |
October – December 2022, Inpatient Hospital and Psych Medical Review Top Denial Reason Codes
We encourage all providers to review this information when filing claims to prevent denials and to ensure their claims are processed timely. The following information affects providers billing the 11X bill type in South Carolina, North Carolina, Virginia and West Virginia.
|
Rank |
Denial Code |
Denial Description |
# Claims |
|---|---|---|---|
|
1 |
Auto Denial — Requested Records not Submitted |
34 |
|
|
2 |
LCD Denial — No Medical Necessity |
10 |
|
|
3 |
Documentation Submitted Does Not Support Medical Necessity |
1 |
|
|
4 |
No Valid Certification, Recertification Present |
1 |
|
|
5 |
Documentation Submitted Does Not Support Medical Necessity for Inpatient Psychiatric Services |
1 |
October – December 2022, Skilled Nursing Facility Medical Review Top Denial Reason Codes
We encourage all providers to review this information when filing claims to prevent denials and to ensure their claims are processed timely. The following information affects providers billing the 21X bill type in South Carolina, North Carolina, Virginia and West Virginia.
|
Rank |
Denial Code |
Denial Description |
# Claims |
|---|---|---|---|
|
1 |
Agree with Provider (Beneficiary Liable) |
21 |
|
|
2 |
Certification Not Valid |
5 |
|
|
3 |
Medical Review Downcode |
5 |
|
|
4 |
Not Medically and Reasonable Necessary |
3 |
|
|
5 |
Auto Denial — Requested Records Not Submitted |
2 |
|
|
6 |
Skilled Nursing Facility Benefits Are Only Available After an Eligible Covered Hospital Stay of at Least 3 Days |
2 |
|
|
7 |
Agree With Provider (Provider Liable) |
2 |
|
|
8 |
LCD Denial — No Medical Necessity |
1 |
|
|
9 |
5D508/5H508 |
Benefits Are Exhausted on a SNF Claim for Services Subject to Benefit Period Determinations |
1 |
5D505 — Certification Not Valid
Reason for Denial
The certification or recertification is not submitted, not signed, not dated, or does not cover the dates of service in question.
To Prevent This Denial
- A certification or recertification statement must be signed by an attending physician or a physician on the staff of the SNF who has knowledge of the case or a nurse practitioner who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the physician, or a clinical nurse specialist who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the physician. Initial certifications must be obtained at the time of admission, or as soon thereafter as is reasonable and practicable
- The routine physician’s admission order is not a certification of the necessity for post-hospital extended care services for purposes of the Medicare program
- When responding to a request for copies of medical records, submit the initial certification and/or subsequent recertifications related to the look back periods and the dates of service under review
More Information
- CMS Manual System, Publication 100-08, Medicare Program Integrity Manual, Chapter 6 — Intermediary MR Guidelines for Specific Services, Section 6.3 (PDF)
- CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 40 (PDF)
- Code of Federal Regulations (CFR)